Growth hormone use in pediatric growth hormone deficiency and other pediatric growth disorders.

The diagnosis and management of growth disorders in children, particularly disorders that respond to therapy with growth hormone (GH), raise challenging clinical and economic issues. Several such issues are presented in the following article in which Dr. Ron Rosenfeld examines the evaluation and diagnosis of the child with short stature; Dr. David B. Allen discusses the anabolic and metabolic indications for GH treatment in children; Dr. Margaret H. MacGillivray reviews GH dosing, height outcomes, and follow up; and Dr. Craig Alter presents the payer's perspective on the diagnosis and treatment of pediatric GH deficiency. In addressing the use of GH in other pediatric populations, Dr. Paul Saenger focuses on Turner syndrome, Dr. Henry Anhalt on chronic renal insufficiency of childhood, and Dr. Ray Hintz on idiopathic short stature. Dr. Harvey P. Katz presents one managed care organization's policy and implementation plan that is used to guide decisions regarding coverage for GH treatment.

Growth hormone coverage policy and implementation: a four-year experience.

Expenditures for growth hormone (GH) in the United States approximates 400 million dollars annually. There is considerable controversy and variation around both the indications for GH treatment and insurance coverage decisions involving GH treatment. To address these issues, Harvard Community Health Plan (HCHP), now merged with Pilgrim Health Care to form Harvard Pilgrim Health Care (HPHC), developed a policy and implementation plan in 1992 which limited access to GH to those conditions for which GH has been shown to be effective. The 4-year experience of the HPHC Growth Hormone Review Committee, which determines by case review whether criteria for GH coverage are met, is described. The result has been a more rational, equitable approach to decisions about GH treatment coverage, and significant cost reductions. Caution is warranted in expanding access to GH because the potential for serious side effects has not been completely eliminated. Four years after the inception of the policy and approval process (1992-1995), it is estimated that savings have exceeded 1 million dollars. Growth hormone prescribing costs decreased from 13.4% of total to 4.4% of total drug costs 4 years after the new policy was implemented. This approach to policy development and implementation may be applicable to managing high-cost pharmaceuticals and advanced technology in other settings.

A 10-year experience in pediatric after-hours telecommunications.

A rapidly growing area within the field of telephone medicine is the use of centralized telephone triage systems to help in the after-hours coverage of pediatric practices. This paper describes a 10-year experience with a pediatric telecommunications program within the 302,000-member Health Centers Division of Harvard Pilgrim Health Care. Telephone volume averages 3,000 calls per month, and over 175,000 telephone calls have been received since the program began. This article highlights the linkage to the primary care physician, the enhancement of service by the automated medical record system, and the application of the telecommunications program to resident teaching. The literature review focuses on the rationale for structured telecommunications programs, including improved quality of care, reduction of medicolegal risk, and the potential for reimbursement of services.

Acute otitis media: who needs posttreatment follow-up?

OBJECTIVE: Because the optimal timing for follow-up of acute otitis media (AOM) is unknown and clinicians' recommendations for timing follow-up are highly variable, a study was conducted to determine which risk factors or symptoms could predict the resolution, recurrence, or persistence of AOM after treatment completion. METHODS: Three hundred four children from a general pediatric practice in a staff-model health maintenance organization, ages 6 months to 4 years diagnosed with AOM were enrolled in a prospective study of the clinical outcome of AOM at 10 to 21 days from diagnosis. Risk factors, symptoms, and parental observations were obtained by questionnaire at both the initial and follow-up visit 10 to 21 days later. At the follow-up visit, the clinical outcome of resolved AOM or persisting AOM was determined by the examining clinician. RESULTS: One hundred eighty-one patients returned for follow-up between 10 to 21 days; 24.9% had AOM at follow-up. Parental impression of resolved ear infection and the absence of symptoms at follow-up identified 97.1% of children with resolved AOM. Other factors associated with increased risk of AOM at follow-up were age < or = 15 months and a family history of recurrent AOM in a sibling. CONCLUSIONS: Because parental judgement of ear status and observation of symptoms appear to accurately identify those children with resolved AOM, a follow-up strategy is proposed in which posttreatment follow-up may be selectively offered to children whose parent(s) feels the infection has not resolved, children whose symptoms persist, or children at higher risk for AOM such as those < or = 15 months or with a family history of recurrent otitis.

Quality telephone medicine. Training and triage.

The telephone is an integral part of medical care, yet it ranks as the number one source of patient and clinician dissatisfaction. Problems fall into three categories: (1) volume overload with access difficulties, (2) staffing and telephone triage, and (3) the stress on clinicians of non-emergency night calls. This paper summarizes a telephone medicine satisfaction survey among HMO pediatric department chiefs, reviews the variables that influence the quality of telephone medicine, and discusses the importance of training in telephone management skills. A four-step approach to improving telephone medicine is presented along with a telephone quality-of-care checklist applicable to most practices.

Variations in utilization of health services by children.

In this longitudinal study in two prepaid group practices, many more children stayed at the same level of use of services over a six- to ten-year period than would be expected if use of services had distributed randomly. Overall, about 13% remained consistently in the highest third of the distribution of use, and another 13% remained consistently in the middle or lowest third. If use of services had distributed randomly, 4% and 7%, respectively, would have been in these groups. Conversely, many fewer children (25%) showed fluctuating patterns of use over time than would be expected by chance alone (37%). Although the reasons for this phenomenon are unknown (and may be multiple), the findings have implications both for clinical care and for development of policy regarding the organization and financing of health services for children.

Quality assessment of a telephone care system utilizing non-physician personnel.

An approach to providing medical care by telephone is described and its content and quality assessed by means of an outcome study. Pediatric health assistants have been trained to evaluate, triage and offer home management advice in lieu of an office visit for medical problems presented by parents via telephone. During a four-week study period, data were collected on all calls (N = 2520) using a telephone encounter form. Fifty-nine per cent of all calls involved requests for care of illness, 30 per cent of which were independently handled by the health assistant. Quality of care was evaluated for those cases who received advice in home management by means of a seven day follow-up interview with parents (N = 247). Access, parent satisfaction, residual symptoms, and the need for further care were ascertained. Greater than 90 per cent of parents expressed satisfaction and 92 per cent of problems had resolved. Results indicate that this telephone care system can effectively sort out and advise parents in home management for the many minor problems which occur in a pediatric practice, thereby increasing time for direct contact with patients.